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ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is November 19, 2021.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40(10):1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133(3):698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21(1):1038.
Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.
Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.
Griffin JA, Carr K, Bersani K, et al. Diagnosis (Berl). 2021;Epub Aug 23.
Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Aasen L, Johannessen A‐K, Ruud Knutsen I, et al. J Clin Nurs. 2021;Epub Sep 28.
Patients receiving hospital-level care at home (hospital-at-home, (HAH) have fewer complications, better patient and family satisfaction, and better outcomes. This study describes nurses’ and physicians’ perspectives of pediatric HAH. Three themes evolved: building a trusting relationship with the child and family; performing essential skills; and acting as the “hub” between families and providers.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.
Budnitz DS, Shehab N, Lovegrove MC, et al. JAMA. 2021;326(13):1299.
Previous studies have utilized data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project (NEISS) to analyze harms from medication use. This study uses updated NEISS data to also describe harms from nontherapeutic medication use. Visits to emergency departments for medication adverse events varied by age group, medication class, and intent of use.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
Fostering a positive safety culture is essential to delivery of safe care. This mixed-methods study of nurses and non-physician health professionals found that staff perceptions of senior leadership, teamwork, and turnover intention were significantly associated with overall patient safety grade.
James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.
Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17(7):e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6(5):e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.

Patient Safety Foundation. October 29, 2021. 10:30--11:30 AM (eastern).

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar will discuss how different stakeholders might view approaches to medical error management. It will describe how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71(708):e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.